MEDICAL BENEFITS
SUBSCRIBER CLAIM FORM
2a-SUBSCRIBER'S LAST NAME 2b-FIRST NAME 2c-INITIAL
2d-SUBSCRIBER IDENTIFICATION NUMBER (Including Prefix)
2e-ADDRESS-NUMBER AND STREET 2f-CITY
2g-STATE 2h-ZIP CODE
SUBSCRIBER /PATIENT INFORMATION
2i-PATIENT'S LAST NAME
2j-FIRST NAME
2k-INITIAL
2L-DATE OF BIRTH
2m-GENDER
2n-PATIENT'S RELATIONSHIP
TO SUBSCRIBER
M
F
SELF
SPOUSE
CHILD
OTHER HEALTH INSURANCE INFORMATION
3a-IS THE PATIENT COVERED BY ANOTHER HEALTH INSURANCE PLAN (INCLUDING MEDICARE)?
3b-NAME OF OTHER POLICYHOLDER
3c-POLICY OR IDENTIFICATION NUMBER
3d-POLICY EFFECTIVE DATE:
3e-TYPE OF POLICY/COVERAGE:
3f-POLICYHOLDER'S DATE OF BIRTH:
_______/_______/__________
yyyy
dd
mm
_______/_______/__________
yyyy
dd
mm
TWO-PERSON
INDIVIDUAL
FAMILY
3g-NAME AND ADDRESS OF OTHER INSURANCE CARRIER
SECTION 2
please complete 3b-3g below
If YES,
YES
NO
Please Note-If the patient has other primary insurance, the Explanation of Benefits form(s) from the other health insurance plan must accompany this
claim form, along with the matching itemized bill.
MOTOR VEHICLE/WORK-RELATED INFORMATION
SECTION 3
4a-ARE THE SUBMITTED EXPENSES RELATED, IN ANY WAY, TO A MOTOR VEHICLE OR WORK-RELATED ACCIDENT OR INJURY?
please complete 4b & 4c below
NO
YES
If YES,
4b-TYPE OF ACCIDENT:
WORK
MOTOR VEHICLE
OTHER
_______/_______/__________
yyyy
dd
mm
4c-DATE OF ACCIDENT OR INJURY:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals information concerning any fact
material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of each violation.
SECTION 5
SIGNATURE AND DATE
DATE:
SUBSCRIBER SIGNATURE:
I CERTIFY THAT THE INFORMATION SUBMITTED IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE THE RELEASE OF ANY RELEVANT
INFORMATION TO MY INSURANCE CARRIER.
______/______/_______
yyyy
dd
mm
SECTION 4
Please enter all information exactly
as shown on your ID card
1b-ITEMIZED BILL(S) FOR SERVICES OR SUPPLIES MUST BE SUBMITTED WITH THIS FORM IN ORDER FOR
1-PATIENT'S FULL NAME AND DATE OF BIRTH
2-NAME AND ADDRESS OF THE PROVIDER OF
3-DATE FOR EACH SERVICE RENDERED
5-CHARGE FOR EACH SERVICE RENDERED
6-DESCRIPTION OF ILLNESS/INJURY AND/OR
7-COUNTRY MUST BE INDICATED AND ALL
4-DESCRIPTION AND/OR VALID PROCEDURE
NO
YES
1a-HAVE SUBMITTED EXPENSES BEEN PAID IN FULL BY YOU?
SECTION 1
INFORMATION REQUIRED FROM SUBSCRIBER
A nonprofit independent licensee of the BlueCross BlueShield Association
8-PRESCRIPTION NUMBER AND NAME OF
PLEASE REVIEW AND LEGIBLY COMPLETE ALL SECTIONS (1-5) OF THIS FORM
Please Note-If you do not have all of the required information, please contact the provider of service for assistance prior to submitting your
claim. Failure to supply all of the required information may result in delayed processing and/or subsequent return or denial of your claim
submission.
If your address has changed or is incorrect, please call our Customer Service Department at the telephone numbers listed on your
identification card.
Please Note-If a participating provider rendered the service(s) being submitted, payment will be made directly to the provider.
SERVICE ON THEIR OFFICE LETTERHEAD,
INCLUDING PROVIDER ID NUMBER AND
CREDENTIALS
CODE FOR EACH SERVICE RENDERED
VALID DIAGNOSIS CODE FOR EACH
SERVICE RENDERED
REIMBURSEMENT TO BE CONSIDERED. THE ITEMIZED BILL MUST CLEARLY INDICATE ALL OF THE FOLLOWING:
INFORMATION TRANSLATED TO ENGLISH FOR
ANY SERVICE(S) NOT RENDERED IN THE USA
PRESCRIBING PHYSICIAN MUST BE INDICATED
ON RX/MEDICINE BILLS
Excellus BlueCross BlueShield
P.O. Box 22999
Rochester, NY 14692
Mail completed form and all required
information to:
MSA-1, Rev 4/09
